Symposium www.jpgmonline.com TTelemedicine elemedicine and Rural Health Care Applications Smith AC, Bensink M, Armfield N, Stillman J, Caffery L The University of ABSTRACTABSTRACTA ABSTRACTABSTRACTBSTRACT Queensland, Centre for Telemedicine has the potential to help facilitate the delivery of health services to rural areas. In the right Online Health, Australia. circumstances, telemedicine may also be useful for the delivery of education and teaching programmes and Correspondence: the facilitation of administrative meetings. In this paper reference is made to a variety of telemedicine applications Anthony C. Smith, in Australia and other countries including telepaediatrics, home telehealth, critical care telemedicine for new E-mail: [email protected] born babies, telemedicine in developing countries, health screening via e-mail, and teleradiology. These applications represent some of the broad range of telemedicine applications possible. An overriding imperative is to focus on the clinical problem first with careful consideration given to the significant organisational changes which are associated with the introduction of a new service or alternative method of service delivery. For telemedicine to be effective it is also important that all sites involved are adequately resourced in terms of staff, equipment, telecommunications, technical support and training. In addition, there are a number of logistical factors which are important when considering the development of a telemedicine service including site selection, clinician empowerment, telemedicine management, technological requirements, user training, telemedicine evaluation, and information sharing through publication. PubMed ID : 16388171 J Postgrad Med 2005;51:286-93 KEY WORDS: Applications, logistics, rural health, telemedicine, telehealth or people living in the rural areas, the distance to main dustrialised and developing countries, cheap, well known and F metropolitan centres often places restrictions on ac- can support ordinary telephony, video telephony and Internet cess to essential services, including specialist healthcare. access. Newer digital networks such as the integrated services Telemedicine provides one possible answer. Many different digital network (ISDN) and broadband technologies are be- terms such as telehealth, telecare, online health and E-health coming more widely available and more affordable for rural have been used but they all have a common meaning, i.e. the telemedicine. use of information and communication technologies to de- liver health care services at a distance. In this paper we describe a range of telemedicine applications used in Australia as well as internationally with emphasis on The motivation for investigating the use of telemedicine for health services which benefit people in rural areas. We also different clinical problems include large distances between explain some of the principal logistical factors which should patients and specialists, isolated health professionals requir- be considered during the conception of a new telemedicine ing specialist support and/or education, and situations where service. there is no other alternative, for example space flight or pa- tients at sea, as well as the pervasive and pragmatic issue of Reasons for doing telemedicine cost. Are health care dollars better spent on sending the clini- cian to the patient, bringing the patient to the clinician, or by The purpose for which telemedicine is used may be catego- facilitating the consultations using telemedicine? rised as one or a combination of the following: clinical, educa- tional and administrative. Modern advances in information communication technologies have seen developments in the different mechanisms avail- For clinical services, sessions generally include interaction be- able for conducting telemedicine, from Morse code to the or- tween clinicians (and may include or exclude the patient). For dinary telephone and more recently the Internet. The differ- example, a primary health care provider could telephone a spe- ent telecommunication networks required to support these cialist to discuss appropriate clinical management of an unu- communication technologies have also advanced. The plain sual case. Alternatively, a digital image of an X-ray could be old telephone system (POTS) is widely available in both in- sent via email to a specialist to assist with diagnosis.[1] 286 J Postgrad Med December 2005 Vol 51 Issue 4 286 CMYK Smith et al.: Telemedicine and rural health care applications For education, sessions may include the delivery of lectures tage of this form of telemedicine is that the recipient of the and workshops to multiple sites using techniques such as information can examine the material at their convenience. A videoconferencing, teleconferencing and web-casting.[2,3] In common example of pre-recorded telemedicine is teleradiology, Queensland for instance, most videoconferencing equipment in which a digital X-ray image is transmitted to a radiologist is currently used by hospitals for educational purposes.[4] Edu- for reporting. cational sessions may involve the delivery of a pre-recorded lecture (videotape or DVD) to a group of students at a remote Real-time telemedicine applications site, or an interactive workshop conducted via videoconference involving several different sites simultaneously. Telepaediatrics Telemedicine can be very useful for the delivery of specialist For administrative applications, communication between dif- paediatric services, hence the use of the term telepaediatrics. ferent sites for management meetings, interviewing interstate/ The best known examples of telemedicine services for chil- [7-9] [10-13] [14,15] international candidates for position vacancies, and keeping dren are in cardiology, fetal medicine and psychiatry. in contact with regional sites are all different types of In terms of general telepaediatrics, i.e. encompassing all pae- telemedicine activity.[5] diatric sub-specialties, the work conducted in Queensland rep- resents the largest body of work reported in the literature to [16] In all cases, telemedicine is used to facilitate a service or activ- date. ity for which the parties would normally have to travel. Since 2000, we have established and evaluated a novel telepaediatric service in Queensland, Australia (Figure 1). Types of telemedicine Queensland is the second largest state in Australia with a popu- lation of about four million people.[17] Given the large distances Regardless of the purpose, there are two main methods of con- in Queensland and that the majority of specialist health serv- ducting telemedicine, i.e. real-time and store and forward (Ta- ices are located in the far south-east corner of the state, pa- ble 1). The choice of method depends on what information tients living in non-metropolitan areas must travel up to 2000 needs to be transmitted, the availability of the appropriate km for their specialist appointment. This usually requires hours telecommunications resources and the urgency of the reply.[6] of driving by car or expensive travel by rail or air. If patients must travel to see a specialist, the health department in Real-time Queensland provides funding to subsidise the costs associated Real-time telemedicine allows participants to send and receive with transportation and accommodation. These costs amount information almost instantly with negligible delay. A common example of real-time telemedicine is a discussion about a pa- United Kingdom tient over the telephone. Videoconferencing is another exam- ple although it requires more expensive equipment. Videoconferencing has the added benefit of being able to view live video images. The advantage of real-time telemedicine is Ireland England that decisions may be made immediately at the time of the Cairns session, and if additional information is required, the clinician can request it immediately. Real-time telemedicine can be valuable when a patient in a remote location is linked up to 0km 500 km their specialist via videoconference for a clinical consultation. Mackay Store and forward applications QUEENSLAND The alternative to real-time telemedicine is “store and forward” Hervey Bay telemedicine whereby information is encapsulated and then transmitted to the recipient for subsequent reply. This method Brisbane is generally cheaper and more convenient. Examples include correspondence via E-mail, fax or the post. The main advan- Figure 1: Queensland Map showing distances Table 1: Telemedicine examples: store and forward and real-time Purpose Store and forward Real-time Clinical Digital images may be sent via email direct to the specialist Videoconferencing may be used for clinical for diagnosis and management advice, e.g. teledermatology, consultations involving the patient, primary care teleradiology. provider (General Practitioner) and specialist at a tertiary hospital. Educational Educational material can be sent by mail in the form of Lectures can be transmitted via videoconference tutorial notes, audio or video resources. to multiple sites simultaneously. Administrative Memo and meeting notes may be mailed by post or Telephone conferencing may be used for fax for perusal at a time that is convenient for the recipient. interactive discussions between participants. J Postgrad Med December 2005 Vol 51 Issue 4 287 CMYK287 Smith et al.: Telemedicine and rural health care applications to more than $25 million per annum.[18] (Figure 3), cardiology, diabetes, ENT (ear, nose and throat), nephrology, neurology